CONTACT:
Robert J. Rosseter, 202-463-6930, x231
[email protected]Fact Sheet:
Creating a More Highly Qualified Nursing Workforce
Quality patient care hinges on having a well educated nursing workforce. Research has shown that lower
mortality rates, fewer medication errors, and positive outcomes are all linked to nurses prepared at the
baccalaureate and graduate degree levels. The American Association of Colleges of Nursing (AACN) is
committed to working collaboratively to create a more highly qualified nursing workforce since education
enhances both clinical competency and care delivery. This fact sheet looks at todays nursing workforce;
highlights research connecting education to outcomes; and outlines the capacity of four-year colleges to
enhance the level of nursing education in the U.S.
Snapshot of Todays Nursing Workforce
According to the National Center for Health Workforce Analysis within the Health Resources and
Services Administration (HRSA), approximately 2.8 million registered nurses (RNs) are currently
working in nursing (HRSA, 2013). This count reflects an increase from the last National Sample
Survey of Registered Nurses conducted by HRSA in 2008 which found that 2.6 million RNs were
employed in nursing (out of a population of more than 3 million licensed RNs).
HRSAs 2013 report, titled The U.S. Nursing Workforce: Trends in Supply and Education, also found
that 55% of the RN workforce held a baccalaureate or higher degree. In a separate study conducted by
the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers
in 2013, the percentage of nurses in the U.S. with a baccalaureate or higher degree was 61%.
Graduates of entry-level nursing programs (baccalaureate degree, associate degree and diploma) sit
for the NCLEX-RN licensing examination. The fact that new nurses pass the licensing exam at the
same rate does not mean that all entry-level nurses are equally prepared for practice. The NCLEX
tests for minimum technical competency for safe entry into basic nursing practice. Passing rates
should be high across all programs preparing new nurses. This exam does not test for differences
between graduates of different programs, measure performance over time, or test for all of the
knowledge and skills developed through a baccalaureate program.
In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing,
initiated by the Robert Wood Johnson Foundation, which called for increasing the number of
baccalaureate-prepared nurses in the workforce to 80% and doubling the population of nurses with
doctorates. The expert committee charged with preparing the evidence-based recommendations
contained in this report state that to respond to the demands of an evolving health care system and
meet the changing needs of patients, nurses must achieve higher levels of education..
In March 2005, the American Organization of Nurse Executives (AONE) released a statement calling
for all for registered nurses to be educated in baccalaureate programs in an effort to adequately
prepare clinicians for their challenging and complex roles. AONEs statement, titled Practice and
Education Partnership for the Future, represents the view of nursings practice leaders and a desire to
create a more highly educated nursing workforce in the interest of improving patient safety and
providing enhanced nursing care.
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Research Linking Nursing Education to Patient Outcomes
AACN and other authorities believe that education has a strong impact on a nurses ability to practice,
and that patients deserve the best educated nursing workforce possible. A growing body of research
reinforces this belief and shows a connection between baccalaureate education and lower mortality rates.
In a study published in the October 2014 issue of Medical Care, researcher Olga Yakusheva from the
University of Michigan and her colleagues found that a 10% increase in the proportion of
baccalaureate-prepared nurses on hospital units was associated with lowering the odds of patient
mortality by 10.9%. Titled Economic Evaluation of the 80% Baccalaureate Nurse Workforce
Recommendation, the study authors also found that increasing the amount of care provided by BSNs
to 80% would result in significantly lower readmission rates and shorter lengths of stay. These
outcomes translate into cost savings that would more than off-set expenses for increasing the number
of baccalaureate-prepared nurses in hospital settings.
Posting online in August 2014 by the International Journal of Nursing Studies, a team of researchers
from several nursing schools in South Korea and the University of Pennsylvania found that a 10%
increase in baccalaureate-prepared nurses was associated with a 9% decrease in patient deaths in
South Korean hospitals. The authors concluded that increasing the number of nurses with the BSN
would significantly reduce the number of in-hospital deaths.
Published in The Lancet in May 2014, authors of the study titled Nurse Staffing and Education and
Hospital Mortality in Nine European Countries: A Retrospective Observational Study found that that
patients experiencing complications after surgery are more likely to live if treated in hospitals with
adequate nurse staffing levels and higher numbers of BSN nurses. Following a review of more than
420,000 patient records in 300 hospitals spanning nine European countries, finding show that a 10%
increase in the proportion of nurses holding a bachelors degree in an acute care setting is associated
with a 7% decrease in the risk of death in discharged patients following common surgeries.
In an article published in the March 2013 issue of Health Affairs, nurse researcher Ann Kutney-Lee
and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a
hospital was associated with an average reduction of 2.12 deaths for every 1,000 patientsand for a
subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients.
In the February 2013 issue of the Journal of Nursing Administration, Mary Blegen and colleagues
published findings from a cross-sectional study of 21 University Healthsystem Consortium hospitals
which found that hospitals with a higher percentage of RNs with baccalaureate or higher degrees had
lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep
vein thrombosis or pulmonary embolism and shorter length of stay.
In the October 2012 issue of Medical Care, researchers from the University of Pennsylvania found
that surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and
12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The
study authors conclude that these better outcomes were attributed in large part to investments in
highly qualified and educated nurses, including a higher proportion of baccalaureate prepared nurses.
In an article published in Health Services Research in August 2008 that examined the effect of
nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr.
Christopher Friese and colleagues found that nursing education level was significantly associated
with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality
and failure-to-rescue rates.
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In a study released in the May 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken
and her colleagues confirmed the findings from their landmark 2003 study (see below) which show a
strong link between RN education level and patient outcomes. The noted nurse researchers found that
every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4%
decrease in the risk of death.
In the January 2007 Journal of Advanced Nursing, a study of 46,993 patients conducted by
researchers at the University Toronto found that hospitals with higher proportions of baccalaureate-
prepared nurses tended to have lower 30-day mortality rates. The findings indicated that a 10%
increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for
every 1,000 discharged patients.
In a study published in the March/April 2005 Nursing Research, Dr. Carole Estabrooks and her
colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive
impact on mortality rates following an examination of more than 18,000 patient outcomes at 49
Canadian hospitals. This study, The Impact of Hospital Nursing Characteristics on 30-Day Mortality,
confirmed the findings from Dr. Aikens landmark study from 2003.
In a study published in the September 24, 2003 Journal of the American Medical Association, Dr.
Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between
higher levels of nursing education and better patient outcomes. This extensive study found that
surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions
of nurses educated at the baccalaureate or higher degree level. A 10% increase in the proportion of
nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.
For more information on the link between nursing education and patient outcomes, see
http://www.aacn.nche.edu/media-relations/fact-sheets/impact-of-education.
Moving Towards a More Highly Educated Nursing Workforce
AACN stands ready to work with the larger nursing community and representatives from associate degree
and diploma programs to expand awareness of degree completion options, facilitate the establishment of
articulation agreements, and enhance the educational preparation of the nursing workforce.
In February 2015, a new study published in Nursing Economics found that the percentage of BSN-
prepared nurses in acute care hospitals is increasing while the employment of associate degree nurses
in these settings is decreasing. This study is titled Do Associate Degree Registered Nurses Fare
Differently in the Nurse Balor Market Compared to Baccalaureate-Prepared RNs?
Employers are recognizing that education makes a difference and are moving to hire the best educated
entry-level RNs possible. According to AACNs survey on Employment of New Nurse Graduates and
Employer Preferences for Baccalaureate-Prepared Nurses released in October 2014, more than 79%
of employers are now requiring or expressing a strong preference for nurses with a baccalaureate
degree. See www.aacn.nche.edu/leading_initiatives_news/news/2014/employment14.
In September 2012, the Joint Statement on Academic Progression for Nursing Students and
Graduates was endorsed by the American Association of Colleges of Nursing, American Association
of Community Colleges, Association of Community Colleges Trustees, National League for Nursing,
and the National Organization for Associate Degree Nursing. This historic agreement represents the
first time leaders from the major national organizations representing community college presidents,
boards, and program administrators have joined with representatives from nursing education
associations to promote academic progression in nursing. This statement represents the shared view
that nursing students and practicing nurses should be supported in their efforts to pursue higher levels
of education. www.aacn.nche.edu/aacn-publications/position/joint-statement-academic-progression
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In March 2012, the Robert Wood Johnson Foundation funded the Academic Progression in
Nursing (APIN) program to advance state and regional strategies to create a more highly
educated nursing workforce. A total of $4.3 million in funding was awarded to the Tri-Council
for Nursing to steer this initiative. Tri-Council members include the American Association of
Colleges of Nursing, National League for Nursing, American Nurses Association and the
American Organization of Nurse Executives.
www.aone.org/membership/about/press_releases/2012/032312.shtml
The nations Magnet hospitals, which are recognized for nursing excellence and superior patient
outcomes, have moved to require all nurse managers and nurse leaders to hold a baccalaureate or
graduate degree in nursing by 2013. Settings applying for Magnet designation must also show what
plans are in place to achieve the IOM recommendation of having an 80% baccalaureate prepared RN
workforce by 2020. www.nursecredentialing.org
In its October 2010 report on The Future of Nursing, the Institute of Medicine states an increase in
the percentage of nurses with a BSN is imperative as the scope of what the public needs from nurses
grows, expectations surrounding quality heighten, and the settings where nurses are needed
proliferate and become more complex. http://thefutureofnursing.org
In May 2010, the Tri-Council for Nursing, a coalition of four steering organizations for the nursing
profession (AACN, ANA, AONE, and NLN), issued a consensus statement calling for all RNs to
advance their education in the interest of enhancing quality and safety across healthcare settings. In
the statement titled Education Advancement of Registered Nurses, the Tri-Council organizations
present a united view that a more highly educated nursing workforce is critical to meeting the nations
nursing needs and delivering safe, effective patient care. In the policy statement, the Tri-Council finds
that without a more educated nursing workforce, the nation's health will be further at risk.
www.aacn.nche.edu/Education/pdf/TricouncilEdStatement.pdf
In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement
of Teaching released a new study titled Educating Nurses: A Call for Radical Transformation, which
recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all
RNs to earn a masters degree within 10 years of initial licensure. The authors found that many of
todays new nurses are undereducated to meet practice demands across settings. Their strong
support for high quality baccalaureate degree programs as the appropriate pathway for RNs entering
the profession is consistent with the views of many leading nursing organizations, including AACN.
www.carnegiefoundation.org/elibrary/educating-nurses-highlights
In the July/August 2009 issue of Health Affairs, Dr. Linda Aiken and colleagues call for adapting
federal funding mechanisms (i.e. Title VIII and Medicare) to focus on preparing more nurses at the
baccalaureate and higher degree levels. This policy emphasis is needed to adequately address the
growing need for faculty and nurses to serve in primary care and other advanced practice roles. The
researchers reported that new nurses prepared in BSN programs are significantly more likely to
complete the graduate level education needed to fill nursing positions where job growth is expected to
be the greatest. http://content.healthaffairs.org
Currently, 679 RN-to-Baccalaureate programs are available nationwide, including more than 400
programs that are offered at least partially online. These programs build on the education provided in
diploma and associate degree programs and prepare graduates for a broader scope of practice. In
addition, 209 RN-to-Masters degree programs are available which cover the baccalaureate content
missing in the other entry-level programs as well as graduate level course work.
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Articulation agreements support education mobility and facilitate the seamless transfer of academic
credit between associate degree and baccalaureate nursing programs. In addition to hundreds of
individual agreements between community colleges and four-year schools, statewide articulation
agreements exist in many areas including Florida, Connecticut, Arkansas, Texas, Iowa, Maryland,
South Carolina, Idaho, Alabama, and Nevada to facilitate educational advancement. See
www.aacn.nche.edu/media-relations/fact-sheets/articulation-agreements.
References
Aiken, L. (2014, October). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care,
52(10), 861-863.
Aiken, L., Sloane, D.M., et al. (2014, May 24). Nurse staffing and education and hospital mortality in
nine European countries: a retrospective observational study. The Lancet, 383(9931), 1824-1830.
Aiken, L.H., Cheung, R.B. & Olds, D.M. (2009, June 12). Education policy initiatives to address the
nurse shortage in the United States. Health Affairs Web Exclusive. Accessed June 22, 2009 at
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w646.
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008, May). Effects of hospital care
environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229.
Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational
levels of hospital nurses and surgical patient mortality, Journal of the American Medical Association,
290, 1617-1623.
American Association of Colleges of Nursing (2013). 2012-2013 Enrollment and graduations in
baccalaureate and graduate programs in nursing. Washington, DC: Author.
American Organization of Nurse Executives. (2005). Practice and education partnership for the future.
Washington, DC: American Organization of Nurse Executives.
Auerbach, D.I., Buerhaus, P.I., & Staiger, D.O. (2015, January-February). Do associate degree registered
nurses fare differently in the nurse labor market compared to baccalaureate-prepared RNs? Nursing,
Economics, 33(1), 8-12, 35.
Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating Nurses: A Call for Radical
Transformation. Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass.
Blegen, M.A., Goode, C.J., Park, S.H., Vaughn, T. & Spetz, J. (2013, February). Baccalaureate education
in nursing and patient outcomes. Journal of Nursing Administration, 43(2), 89-94.
Budden, J.S., Zhong, E.H., Moulton, P., & Cimiotti. J.P. (2013, July 13). The National Council of State
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5
Estabrooks, C.A., Midodzi, W.K., Cummings, G.C., Ricker, K.L. & Giovanetti, P. (2005, March/April).
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DC: National Academies Press.
Kutney-Lee, A., Sloane, D.M. & Aiken, L. (2003, March). An increase in the number of nurses with
baccalaureate degrees is lnked to lower rates of postsurgery mortality. Health Affairs, 32(3), 579-586.
McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M. & Aiken, L.H. (2012, October). Lower
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National Council of State Boards of Nursing (See Budden, et al. reference above)
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L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients.
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Van den Heede, K., Lesaffre, E., Diya, L., Vleugels, A., Clarke, S.P., Aiken, L.H. & Sermeus, W. (2009).
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Last Update: March 19, 2015
